=Paper=
{{Paper
|id=Vol-3191/paper29
|storemode=property
|title=Implementation of e-learning Platform for Increasing Digital Health Literacy as a Condition for Integration of e-health Services with PHR
|pdfUrl=https://ceur-ws.org/Vol-3191/paper29.pdf
|volume=Vol-3191
|authors=Natasha Blazeska-Tabakovska,Ilija Jolevski,Blagoj Ristevski,Snezana Savoska,Andrijana Bocevska
|dblpUrl=https://dblp.org/rec/conf/isgt2/Blazeska-Tabakovska22
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==Implementation of e-learning Platform for Increasing Digital Health Literacy as a Condition for Integration of e-health Services with PHR==
https://ceur-ws.org/Vol-3191/paper29.pdf
Implementation of e-learning Platform for
Increasing Digital Health Literacy as a Condition
for Integration of e-health Services with PHR
Natasha Blazeska-Tabakovska 1, Ilija Jolevski 1, Blagoj Ristevski 1,
Snezana Savoska 1 and Andrijana Bocevska 1
1
Faculty of Information and Communication Technologies, University “St. Kliment
Ohridski”, ul. Partizanska bb, Bitola, 7000, Republic of North Macedonia
Abstract
Digital healthcare self-management education has the potential to increase
the necessary knowledge and skills for the improvement of health outcomes
for citizens, especially patients with a disability and chronic diseases. If the
implementation of the e-health concept has to be considered, it is obvious
that there is an emerging need for increasing the digital health literacy of
the population. First, the digital health literacy of healthcare and medical
staff has increased and in the second phase, disabled people, chronic
disease patients, and the elderly have to be educated about their digital
health literacy in order to use e-health services. The use of information
and communication technologies provides an effective and efficient way to
deliver health content prepared by medical staff as well as psychologists.
The paper highlights the process of implementation of the e-learning
platform for digital health literacy – Atutor, an open-source learning content
management system suitable for a wider population with implemented
WCAG compliance, and the challenges arising during its implementation
Keywords
Personal Health Record (PHR), patient-centric data integration, cloud-
based PHR, Internet of Medical Things, medical sensors
1. Introduction
Managing care for the growing elderly population and increasing number
of patients with chronic non-communicable diseases requires effective measures
such as involvement and empowerment of patients in self-care. Additionally, the
coronavirus (COVID-19) pandemic had a huge impact on the normal lives of
Information Systems & Grid Technologies: Fifteenth International Conference ISGT’2022, May 27–28, 2022, Sofia, Bulgaria
EMAIL: natasa.tabakovska@uklo.du.mk (N. Blazeska-Tabakovska); ilija.jolevski@uklo.du.mk (I. Jolevski); blagoj.
ristevski@uklo.du.mk (B. Ristevski); snezana.savoska@uklo.du.mk (S. Savoska); andrijana.bocevska@uklo.du.mk
(A. Bocevska)
© 2022 Copyright for this paper by its authors.
Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
CEUR Workshop Proceedings (CEUR-WS.org)
people and led to the advent of a new normal. People increasingly use digital
technologies and the Internet to do every day professional, private as well health
activities. The project Cross4all addresses the e-health challenges in the cross-
border area, taking into consideration the problems of creating a PHR (Personal
Health Record) for patients from two national healthcare systems where the pa-
tient is the data owner. The proposed architecture is cloud-based and distributed,
in order to support data collection from different types of sources and collected
in different ways such as patients’ healthcare data, medical practitioner data, data
collected from biomedical devices, sensors for measuring vital signs of life, many
times collected from remote patients, the disabled population, children and el-
derly people [1].
The increased use of internet access and use of digital technology leads to
people relying on received and sent health information. The potential for health
technologies to be the catalyst for significant advances in healthcare cannot be
questioned, however from a scientifically standpoint, there is still much to be
done to create platforms and systems that activate and engage those who would
benefit from knowing before health issues arise and are too far along to be re-
versed or effectively managed [2]. There are also challenges when it comes to the
systematic assessment of the reliability of health information and unreliability
has a negative impact. The use of social media requires analytical skills to evalu-
ate various information in a smart way.
Today, digital literacy has been dubbed as a fourth literacy, after reading,
writing, and mathematics are considered the cornerstone of being literate.
There are many advantages to having high-level digital Health literacy
skills—they allow patients to operate well within the health care system and find
better care by using online information more effectively, reduce waiting periods
and improve communication with healthcare professionals. Research has found
a positive connection between digital health literacy and joint patient–medical
professionals’ decision-making, [3] as well as clear advantages for patients’ deci-
sion-making styles [4].
The e-learning platform as a part of the Cross4all project makes a positive
impact, increases the participants’ e-health and healthcare digital competencies,
and speeds up the process of healthcare self-management.
The paper describes the implementation of an e-learning platform available
cross-border in a real environment. After the introductory section, the second
section presents research results regarding the digital and health literacy of the
pilot project participants. In the next section, the paper considers some points of
project aim and purpose, prerequisites, and security and safety standards, taken
into account in the phase of LMS (Learning Management System) selection. The
next section describes some of the challenges and obstacles and presents real
336
solutions. The concluding section contains supportive concluding remarks and
proposes some project improvements.
2. Digital health literacy
The Internet abounds with health information. For an illustration, about
3,770,000 results are returned by Google when searching for “blood pressure”
and about 3,910,000 results when searching for “diabetes”.
In order to use digital information, three preconditions need to be met: access
to a computer and high-speed internet; the digital literacy skills needed to use the
computer; and necessary skills to evaluate online health information resources.
Digital health literacy is a set of basic skills acquired through effective digital
technology to search, understand, and evaluate an individual’s health informa-
tion. This relates to the use of digital health technology in the online environment
and to apply the knowledge acquired [5].
The level of digital literacy of the population in the border region is signifi-
cant. In order to determine how and to answer other important questions, a survey
was conducted.
The analyzed research results show that 79% of adults use a smartphone,
tablet and/or computer. Respondents rated the internet connection as satisfactory
and good 73.4%, while 23.2% from very good to excellent, and 3.4% poor or
have no Internet access at all.
57.9% say that they used digital devices to look online for digital health
content within the past year. 34,4% find easy information and services related to
health, 34% find information with difficulty and 31,6% say that they do not find
such information and data (Figure 1). The language was highlighted as one of the
problems in accessing the necessary health content (81.6%). They prefer health
content in the Macedonian/Greek language, their respective mother tongue. The
respondents who access the digital health content find it helpful to find informa-
tion regarding their health problems and possible. Some of them say they use the
internet as a de facto second opinion.
Most of the respondents, 64.2%, believe that the accuracy and importance
of the information depend on the source of the information, and the information
obtained through the Internet sometimes is incomplete, confusing, and in some
cases inaccurate. Only a small percentage 25.3% check the accuracy of the in-
formation and 10.5% do not find important and useful digital health information
(Figure 2).
337
Figure 1: Access to health informa- Figure 2: Accuracy and importance of
tion and services digital health information
Following the results obtained from the research, we estimated that within
the Croos4all project it is most appropriate to develop a digital learning platform
that is easy to use and that incorporates the motto of the project a Cross4all pro-
moting safe aging, early prevention, and independent living for all.
The digital learning platform will help project participants to know how to
use the mobile application as well as help citizens from cross-border regions to
use technologies to manage learning, keep up with any changes and encourage
them to seek knowledge by themselves, from digital media and social media [5].
The e-material was created and posted on the e-learning platform, taking into
consideration the needs of disabled people, the elderly population, and children.
This platform is free, accessible from anywhere, on disposal to the population with
many video materials, presentations, and brochures that have to support the proj-
ect’s aim of increasing the population’s e-health and digital health literacy [6].
The manuals about the new workflow and mobile applications, tutorials, and
technical support needed for integration of e-health Services with PHR during
the pilot project were prepared by two project partners (the Aristotle University
of Thessaloniki, Department of Medicine and University “St. Kliment Ohridski”
– Bitola, Faculty of Information and Communication Technologies). The health
content about diabetes, cardio, Covid-19, and psychology, posted on the digital
platform was prepared by medical professionals (Figure 3). The content is avail-
able in three languages: English, Macedonian, and Greek.
Figure 3: Available courses on the Cross4all e-learning platform
338
Several tasks need to be completed before the e-learning platform is imple-
mented choosing the most suitable LMS; UI (User Interface) compliance with
the WCAG (Web Content Accessibility Guidelines) standard; preparation of the
content and upload to the platform; defining content groups and menus; content
placement and preparation of documentation.
3. Analysis of different learning management systems
Learning Management Systems (LMS) are considered as platforms for e-
learning, taking into consideration their capability and accessibility from differ-
ent points of view.
LMS have big potential for continuous improvement of digital and health
literacy. There is a plethora of available LMS, and each one has different fea-
tures, which are tailored to the different needs of the target groups. To find and
choose the most appropriate LMS is a very important task, and it has a big im-
pact on health literacy improvement [6]. Although there are many user-friendly
developed LMS algorithms to help make choosing the best LMS easy, choosing
the appropriate LMS in accordance with the WCAG standard, that is aimed to
increase the digital and health literacy of the population of the cross-border area
in of Cross4all project of IPA2, was a challenging task [6].
We made research and analyzed some respectable e-learning systems with
W3C’s Web Accessibility principles, defined by ISO 9241-171:2008 standard as
priority (in mind). In the research, considerable attention was dedicated to the
following four principles: Perceivable, Operable, Understandable, and Robust in
order to provide the basics of web accessibility with 12 guidelines for the authors
[7]. For each guideline, we provided testing according to WCAG 2.0 for three
levels of compliance: A (lowest), AA, and AAA (highest) [8].
The analysis was performed on the latest public version of the respective
Learning management systems (LMSs) such as Moodle, Eliademy, Docebo,
Sakai, and ATutor, considering the WCAG 2.0 standards and criteria.
Each of the analyzed LMSs presents a different learning platform with
unique features. Although the accessibility of learning management systems is
improving, there are still significant challenges for people with disabilities [9].
According to the Cross4all requirements, the criteria from WCAG 2.0 Level AA
compliance need to be satisfied.
Our further testing continues with the evaluation of the criteria of Level AAA
for Moodle and ATutor, as these two systems are particularly prominent in terms
of availability for people with disabilities in the previous evaluation [9].
WCAG 2.1 provides 17 new success criteria for different levels of compli-
ance. The five new success criteria for level A: Character Key Shortcuts, Pointer
Gestures, Pointer Cancellation, Label in Name, Motion Actuation. Seven respec-
339
tive criteria from Level AA: Orientation, Identify Input Purpose, Reflow, Non-
Text Contrast, Text Spacing, Content on Hover or Focus, Status Messages; and
five new criteria for Level AAA which is the highest and also least common level
of compliance: Identify Purpose, Timeouts, Animation from Interactions, Target
Size, Concurrent Input Mechanisms. All these criteria were compared in a real
environment, on publicly accessible latest versions of Moodle and ATutor [10].
ATutor was selected as more suitable for the project activities of Cross4all
IPA2, as an LMS that has to satisfy the demands of elderly people, children,
people with chronic diseases as well as people with disabilities in order to in-
crease e-health and medical digital literacy for the cross border region, including
all partners’ contribution [10].
4. Implementation challenges
ATutor, as an open-source LMS, gives the opportunity to develop and man-
age online courses, and to create and distribute interoperable e-learning content.
ATutor is designed with accessibility as a priority. The newest version of ATutor
is adding course gamification and refinements [11].
This LMS has a user-friendly UI, which makes it an ideal tool for beginners
as well as people with disability. It has integrated one of the general principles
that underlie the Convention on the Rights of Persons with Disabilities to provide
access to all aspects for all people on an equal basis. It means “universal design”,
design usable by all people, to the greatest extent possible, without the need for
adaptation or specialized design [12]. Besides the Accessibility features which
are the most important attribute for people with disability and elderly people, it
has the best communication tools with a user-friendly interface and encapsulates
multimedia help of Handbook. Moreover, ATutor has the user-friendly JavaScript
WYSIWIG editor, which is appropriate for a wide community of users and has
many useful features differently from others, such as a glossary, users online and
search bar, latest discussion topics on the forum, and a site-map with an ARIA
tree [6]
The implemented e-learning platform (http://atutor.cross4all.uklo.edu.mk/
login.php) contained much public content: manuals about the new workflow and
mobile applications, tutorials, technical support, and health content. All contents
are available in three languages: English, Macedonian and Greek languages (Fig-
ure 4).
340
Figure 4: Ability to choose between three languages
The users can register themselves, log in on Cross4all LMS and improve
their e-health literacy in many areas such as cardiology, psychology, diabetes,
how to use gadgets for measuring vital signs, and so on. The selected content can
be viewed online or be exported – downloaded and viewed offline.
The user can change elements of their personal profile, can enroll in courses
that they are interested in, can control which versions of content are displayed, if
for example, the primary version is not accessible to them, or they prefer an alter-
nate format. Also, users can develop a network of contacts, create and participate
in social groups, develop a social profile and use different gadgets (a user can add
some of the available applications to their Social Networking environment that
provide a whole range of potential networking functionality). Additionally, they
can create “My Contacts“ – a list of people in the user’s social network.
Although the platform offers a number of possibilities, during the implemen-
tation as well as during its use we faced some challenges.
Some of the problems that we were facing during implementation include
lack of documentation or outdated documentation, installation instructions that
were for older and legacy systems, and older versions of operating systems. One
of the things is that we were trying to virtualize/dockerize the application for it
to be easily movable to staging and production environments. ATutor supports
several types of databases and we decided to go with the MySQL database.
The system has one big problem when it is not properly shut down. Then, it
loses some of the configuration information, and then it needs to be reverted to
some previously configured valid version. The additional downside of using a not
properly configured MySQL database was that it did not support utf-8 character
341
sets, we had significant challenges regarding implementation of the Cyrillic, and
Greek alphabet and we needed to manually configure and provide support for
such alphabets. Atutor is not an up-to-date system and does not provide the latest
support for new versions of internet browsers, the latest version of the system has
been released in 2018.
Because of the complexity of healthcare, and a large number of health top-
ics, we are faced with the problem of finding digital and objective information
accessible to both healthcare providers and patients. Content for patients with
objective and irrelevant health information is the most requested to be prepared
by medical professionals.
Medical professionals are pressed to integrate health IT into their jobs, while
also trying to stay up-to-date with emerging technologies. They often have to deal
with low-quality, bugged, or inefficient software and technologies that further
decrease the amount of time they can spend with their patients [13]. Healthcare
professionals are supposed to provide help to a big number of patients in a given
time frame. Additionally, healthcare professionals were overloaded due to the
coronavirus (COVID-19) pandemic. They are frustrated that health IT requires
their increased engagement, needs long data entry, decreases the amount of time
spent on health digitalization processes, and disrupts it instead of helping their
practice.
One more challenge we faced with was the older patients’ lack of digital
literacy.
5. Conclusion
Designing and implementing an e-learning platform for increasing digital
health literacy in the Cross4all project is one of the components of the digital
health system (which we are keen to be just one part of a larger health system
in both cross-border countries). The process to build and sustain a functional
platform is made up of several stages: choosing the most suitable LMS; UI com-
pliance with the WCAG standard; preparation of the content upload platform;
documentation preparation and platform maintenance.
The dynamic nature of technology and healthcare made the process of imple-
mentation and maintenance non-linear and iterative. Some of the challenges we
faced sometimes had to revert to some previously configured valid version, re-
garding implementation of the Cyrillic and Greek alphabet and the need to manu-
ally configure and provide support for such alphabets. Another big challenge is
the preparation of heath content. This needs some systematic solution. Additional
patients’ training of platform usage was needed.
In future work, we have to work on a digital learning platform that will fea-
ture special courses related to health literacy. This means the ability to obtain,
342
read, understand, and use healthcare information in order to make appropriate
health decisions and follow instructions for treatment. For example addressing
or solving various health problems, and courses related to digital health l health
literacy (set of skills, knowledge, and attitudes that a person needs in order to (a)
seek, find, and appraise health information and services from electronic sources,
and (b) to find, select and make effective use of available tools (PHRs, devices,
mobile apps, etc..
6. Acknowledgment
Part of the work presented in this paper has been carried out in the frame-
work of the project “Cross-border initiative for integrated health and social ser-
vices promoting safe ageing, early prevention and independent living for all
(Cross4all)”, which is implemented in the context of the INTERREG IPA Cross
Border Cooperation Programme CCI 2014 TC 16 I5CB 009 and co-funded by the
European Union and national funds of the participating countries.
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